ML20010C106
| ML20010C106 | |
| Person / Time | |
|---|---|
| Issue date: | 08/12/1981 |
| From: | James Keppler NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III) |
| To: | Lister W FORT HAMILTON-HUGHES MEMORIAL HOSP. CENTER, HAMILTON |
| Shared Package | |
| ML20010C107 | List: |
| References | |
| EA-81-019, EA-81-19, NUDOCS 8108190127 | |
| Download: ML20010C106 (1) | |
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Fort Hamilton Hughes Memorial Licens M 2091-05 Hospital Center ATTN:
W. E. Lister Radiological Administrator 630 Eaton Avenue Hamilton, OH 45013 Gentlemen:
Y This refers to the investigation conducted by Messrs. C. H. Weil, W. J. Adam and R. E. Burgin of our office on September 30, 1980, through January 21, 1981, regarding the unplanned exposure to radiation from a cobalt-60 teletherapy unit of a patient and two technicians experienced at Fort Hamilton Hughes Memorial Hospital Center on September 25, 1980.
During this investigation certain of your activities appeared to be in non-compliance with NRC requirements, as specified in enclosed Appendix A.
A written response, submitted under oath or affirmation, is required.
In a Notice of Violation and Notice of Proposed Imposition of Civil Penalties i
which was sent to you with our letter dated March 3, 1981, three items of apparent noncompliance were set forth.
In your letter dated April 3, 1981, you responded to the three items and provided additional information which led us to conclude that the first item could not be supported. Accordingly, the first item was deleted and we had no further questions in regaru ta Items 2 and 3.
Although the first item of apparent noncompliance was deleted because it did not accurately describe a problem that existed on September 22, 1980, and the morning of September 25, 1980, we have concluded that the actions taken by a teletherapy technician on the afternoon of September'25, 1980, while the source was in an "0N" position did not meet the requirements of
. License Condition 23.
Specificially, the technician entered the treatment room while the Prime Alert radiation monitor was activated. However, the technician was not aware of an emergency condition or did not heed the monitor which indicated the conditiou.
In fact, the technician.was in the treatment room for about 1-1/2 minutes before a second technician entered the room'and realized that an emergency condition existed. Not until that time was an emergency response initiated. Accordingly, we are issuing a revised Notice of Violation which includes a new item of noncompliance related to this matter. No civil penalty is proposed for the item of non-compliance shown in the revised Notice of Violation.
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l Fort Hamilton Hughes Memorial August. 12, 1981 Hospital Center In regard to the revised Notice, it should be noted that the system designed to prevent or mitigate a serious safety event included the source position indicator lights, the Prime Alert radiation monitor and the individual who must initiate a response to an indicated emergency situation. On the after-noon of September 25, 1980, the Prime Alert radiation monitor indicated an emergency situation but the technician was unaware of the significance of the activated Prime Alert or perhaps did not see it.
In your response to the revised Notice of Violation describe what steps management has taken to assure us that all individuals who operate the teletherapy unit have a thorough understanding of all safety devices, s:11 inititate a prompt response to an emergency, and will immediately r.ot ify management of the event. We are also concerned that when the teo.aician observed a recurring problem with the source position indicator lights (both red and green lights were activated) it was not brought to management's attention.
In your response to the revised Notice of Violation describe what steps you have taken or will take to assure us that management will be promptly notified of abnormalties, will evaluate them, and will take appropriate action.
In accordance with Section 2.790 of the NRC's " Rules of Practice," Part 2, Title 10, Code of Federal Regulations, a copy of this letter and the en-closure will be placed in the NRC's Public Document Room.
Sincerely, James G. Keppler Director
Enclosure:
Revised Appendix A, Notice of Violation cc w/ encl:
DMB/ Document Control Desk
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